Family meal frequency, weight status and healthy management in children, young adults and seniors. A study in Sardinia, Italy

Appetite 89 (2015) 160–166

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Research report

Family meal frequency, weight status and healthy management in children, young adults and seniors. A study in Sardinia, Italy ☆ Gianfranco Nuvoli * Developmental Psychology, Department of History, Human Sciences and Formation, University of Sassari, Via Zanfarino 62, 07100 Sassari, Italy

A R T I C L E

I N F O

Article history: Received 23 September 2014 Received in revised form 13 January 2015 Accepted 2 February 2015 Available online 10 February 2015 Keywords: Family meal frequency Weight status Adult and elderly nutrition Lifespan

A B S T R A C T

Objective: To examine family meal frequency, and weight management as a protective factor throughout life. Participants: Selected by city and by town in Sardinia (Italy), the 522 participants were divided into 162 children (7–11 years), 187 young adults (19–30 years), and 173 seniors (65–90 years). Method: Chi-square analyses were used to compare the frequency of family meals, weight (self-reported and perceived) and healthy management (physical activity, dieting, perceived appetite) between age groups. In addition, multinomial regression analyses were carried out to find associations, with age group as the dependent variable and frequency of family meal, weight status, and healthy management categories as independent variables, adjusted for moderating effects. Results: Significant associations with age variables were observed in mealtime frequency (skipping breakfast and mid-morning snack in adults and lunch in children and seniors), in decreasing self-reported normal weight with age and increasing perceived overweight with age, and in physical activity, dieting and perceived appetite. Conclusions and Implications: The results suggest the protective nature of family meals for adults and seniors, and identify significant associations (and some differences) between age groups. Discrepancies suggest the importance of education about body weight awareness throughout life. © 2015 Elsevier Ltd. All rights reserved.

Introduction Nowadays, our focus on obesity as a ‘social epidemic’ (WHO, 2000) stems from our opinion about this phenomenon and its expansion in recent decades. In the US, two out of three adults and one child or teenager out of six are labelled as overweight or obese (Flegal, Carroll, Ogden, & Curtin, 2010), and in other Western countries, the number of overweight/obese children and teenagers is increasing. In Northern Italy, a study of 10 and 11 year old children shows a prevalence of 16% and 7% respectively (Gnavi et al., 2000). Given that childhood obesity persists in adulthood, excess weight is a strong predictor of obesity and the risk of related conditions such as cardiovascular illness, type 2 diabetes and hypertension (WHO, 2000). The impact of excess weight and obesity on health has given rise to many studies on predictive factors for its prevention. Some have not yet been fully explored while others confirm the multidimensional nature of obesity, due to factors which influence dietary models and weight at a psycho-social and socio-economic level (Berge et al., 2012; Eisenberg, Olson, Neumark-Sztainer,

☆ Acknowledgments: This work was supported in part by the FARR fund (ex 60%) from University of Sassari (Italy). The author declares that there are no conflicts of interest. * E-mail address: [email protected].

http://dx.doi.org/10.1016/j.appet.2015.02.007 0195-6663/© 2015 Elsevier Ltd. All rights reserved.

Story, & Bearinger, 2004; Øvrum, Gustavsen, & Rickertsen, 2014). Among these protective factors, the frequency of family meals (FFM) plays an important role, in which there is an inverse relationship with conditions of overweight and obesity (Chan & Sobal, 2011; Mestdag, 2005; Neumark-Sztainer, Wall, Story, & Fulkerson, 2004). FFM can influence both dietary behaviour and body weight qualitatively and quantitatively. Several studies show an inverse relationship between FFM and body weight in parents and children (Chan & Sobal, 2011; Neumark-Sztainer et al., 2004; Sen, 2006). This relationship seems to apply to gender, region, ethnic group and socio-economic status (Larson et al., 2013; Rollins, Belue, & Francis, 2010; Veltsista et al., 2010). Longitudinal studies show a positive association between FFM and healthy eating habits in teenagers and young adults (Burgess-Champoux, Larson, Neumark-Sztainer, Hannan & Story, 2007; Larson, Neumark-Sztainer, Hannan, & Story, 2007), whereas a positive association with Body Mass Index (BMI) is not always confirmed (Berge et al., 2012; Sen, 2006; Taveras et al., 2005; Utter et al., 2013). Eating meals together does not just mean the physical presence of parents around the table or “sitting down and mechanically eating with others” (Chan & Sobal, 2011), but it is also an important ritual for interacting with family members, keeping the family united and solving conflicts. The importance of the psychological factor of FFM and its potential long-term benefits derives from the influence of this important daily moment of socialisation, which

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leads to psychophysical wellbeing and correct eating habits (Boutelle, Lytle, Murray, Birnbaum, & Story, 2001). Research into FFM shows how this moment is a protective factor in monitoring and modelling the choice of the quality and quantity of food (Hays, Power, & Olvera, 2001). In fact, this habit in adolescence is associated with better diet and health in adult life. Even in later years, it promotes parental cohesion and is a protective factor for psychological wellbeing, due to its positive association with social competences, future prospects and self-esteem (Eisenberg et al., 2004; Larson et al., 2007). Instead, it has a negative association with high-risk behaviours (Fulkerson, Kubik, Story, Lytle, & Arcan, 2009), eating disorders, alcohol and substance use (Eisenberg et al., 2004; Franko, Thompson, Affenito, Barton, & Striegel-Moore, 2008), stress and depressive symptoms (Roberts & Duong, 2013; White, Haycraft, & Meyer, 2014). Data suggest that the majority of young people in the US eat meals with their family 4–5 days a week (Abraczinskasa, Fisak, & Barnesc, 2012; Boutelle et al., 2001), but highlights the progressive temporal and social deconstruction of the dietary model based on 3 meals a day (Mestdag, 2005). There is a decline in FFM in Southern Europe and Italy and in Sardinia, where there is a fall in the intake of breakfast and the Mediterranean diet, both of which are replaced by the Anglo-Saxon diet and fast food (Tessier & Gerber, 2005). Associated with improved health and longevity (Zbeida et al., 2014), the Mediterranean diet is characterised not only by food choices (e.g. olive oil), but also by time and importance of meals (ISTAT, 2013; Tessier & Gerber, 2005). Studies on FFM suggest that the presence of children makes adults set an example when serving healthy food at mealtimes (Fulkerson, Larson, Horning, & Neumark-Sztainer, 2014). Other studies compare FFM with factors such as body weight and behaviour of family members (Berge et al., 2012; Chan & Sobal, 2011); it is the mother in particular who has a positive association with her child’s diet (Boutelle, Birkeland, Hannan, Story, & Neumark-Sztainer, 2007; McIntosh, Kubena, Tolle, Dean, & Anding, 2010). Empirical research has not yet studied FFM from a lifespan developmental perspective. Few studies consider adults except as relatives of children involved in dietary education projects (Berge et al., 2012; Boutelle et al., 2007; Larson, Harnack, & Neumark-Sztainer, 2011; Sobal & Hanson, 2011). Otherwise, they study elderly people only if they are widowed (Rosenbloom & Whittington, 1993), community-dwellers (Quigley, Hermann, & Warde, 2008; Shahar, Shai, Vardi, & Fraser, 2003), homebound (Locher et al., 2009) or deprived (Holmes, Roberts, & Nelson, 2008). In recent literature, a review by Fulkerson et al. (2014) about associations with eating meals with other people highlights that “there may be important positive nutritional benefits.” Healthy choices remain during young adulthood and the negative influences of the socio-economic environment decrease (Larson et al., 2011), but there is also a protective effect of lifestyle choice, including physical activity which shows a positive association with family function (Berge, Wall, Larson, Loth, & Neumark-Sztainer, 2013; Øvrum et al., 2014). Since the meals involve all family members including adults and the elderly (Sobal & Hanson, 2011), further research is required to determine if there is any association with FFM from a lifespan developmental perspective. FFM as a protective factor for the balanced development of a person has led us to differentiate between children and older age groups. The main aim of this study is to analyse the relationships between the different age groups with FFM (breakfast, snack, lunch and dinner), their body weight and their use of diets and physical exercise. We have assumed that children, young adults and the elderly have different relationships with i) family meals; ii) perception of body mass; iii) weight control strategies (diet, exercise and appetite).

161

Methods Subjects and methods A population-based cross-sectional survey according to demographic criteria (ISTAT, 2006) was conducted by recruiting a representative sample of inhabitants of Northern Sardinia (Italy) using a proportionate geographic cluster sampling method. The samples were selected from the city of Sassari (>100,000 inhabitants, 38%), from towns of under 50,000 inhabitants (35%), and from towns of under 5000 inhabitants (27%). In order to highlight any differences linked to age, the two intermediate groups of adolescents (12–18) and adults (31–64) were excluded from the final sample. In order to have a representative sample, participants were selected according to their residential district in the city (old town, suburbs) or according to the type of smaller place they live in (inland, coastal, mountain towns). Young people were chosen from school classes in the selected districts and towns. Young adults were selected from study courses and places of work. Elderly people were chosen according to their houses, social centres and residential centres. The response rate obtained was 96.1% (593 questionnaires out of 650). After eliminating the respondents who had missing demographic data (n = 34), who did not complete all the answers (n = 13), or who had illnesses that would interfere with the study (n = 24), distribution by socio-economic status (SES) according to profession was: 18% low, 40% low-middle, 22% middle, 14% uppermiddle, and 6% high class. The sample was equally distinct for gender (50% males and 50% females), and for age group of children (7–11 years), adults (19–30 years) and seniors (65–90 years). The 522 participants were divided into 162 children (31%, mean = 9.8 years, SD = 1.08), 187 adults (36%, mean = 24.2 years, SD = 3.42), and 173 seniors (33%, mean = 78.2 years, SD = 7.79). The researchers explained the study carefully to each participant and their informed consent was obtained (parents gave consent for their children). The interviewers read each question and the answer options to the participants who then marked their answer on the questionnaire. No Italian Institutional Review Board approval was required for this research, but this paper complies with the rules of the ethical code for research and teaching of the Italian Association of Psychology, both in its general principles and in specific rules; it is also in accordance with Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects.

Questionnaires The questionnaire consisted of two parts. The first one included personal and demographic data, and in the second part, FFM was assessed with a question derived from one previously used in the University of Minnesota EAT (Eating Among Teens) study (Neumark-Sztainer, Larson, Fulkerson, Eisenberg, & Story, 2010). The questions about physical activity (Sánchez-Villegas et al., 2001; Taveras et al., 2005), dieting (Berge et al., 2012; Woodruff & Hanning, 2009), perceived body image (PBI) (Steenhuis, Bos, & Mayer, 2006), and self-described appetite (Rosenbloom & Whittington, 1993; Shahar et al., 2003) were derived from other previously published studies. An Italian version of the questionnaire was developed using a back translation method. The original questions were translated into Italian and another person translated the new version of the questionnaire into English to find any discrepancies between the two versions. The questionnaire was tested both as the reformulation of the English version (with non-Italian children) and in its final

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Italian version. The final questionnaires were administered by faceto-face interviewers with the help of an expert.

Results Descriptive analysis

Measures Socio-demographic variables Self-reported socio-demographic variables included age, gender, marital status and family residence. Socio-economic level was based on occupational status (for children, on the occupation of both parents). Meal frequency To assess frequency of breakfast the following question was asked: “During the past week, how many days did you eat breakfast in your family?” Similar items were used to determine mid-morning snack, lunch and dinner consumption. Responses included never, 1–2, 3–4, 5–6 days, and every day/week. The response options were collapsed into 0–2, 3–6, and 7 day/week. Weight status BMI was calculated based on self-reported height and weight measurements obtained from the questionnaires, using the formula BMI = kg/m2. To assess child weight status, measured height and weight was translated into gender- and age-adjusted BMI percentiles using the guidelines set by the WHO (1995). The participants were divided into 3 categories: Underweight was defined as a BMI of less than 18.5, normal weight was of greater than or equal to 18.5 but less than 25, overweight was 25 or higher. Perception of weight status (PBI) Respondents were asked to classify their body weight, measured on a 5-point scale varying from ‘I am very underweight’ to ‘I am very overweight’. Responses were collapsed into underweight, normal weight and overweight. Self-described appetite Respondents were asked to rate their appetite using the question ‘How would you describe your appetite?’ A scale from 1 to 5 was used, 1 being ‘never get hungry’ and 5 ‘excellent appetite’. Responses were collapsed into 3 categories: ‘poor’, ‘average’, or ‘good’. Weight management This was investigated by two separate items: “During the past week:” (1) “how many hours of physical and sporting activities did you do?” Responses options were recoded to: none, 1–3, and 4 or more/ week. (2) “have you dieted to lose weight or gain weight?” Response options were “yes” or “no” or “no, but I would.” Statistical analyses Frequency distributions of the various categorical outcomes were trichotomised. Chi-square analyses were used to compare differences between age groups in food behaviour (FFM), weight (BMI and PBI), and healthy management. A separate multinomial regression model was conducted to investigate associations with each age group as the categorical dependent variable; FFM, self-reported/perceived weight, and healthy management (physical activity, dieting, perceived appetite) were entered as continuous independent variables, with a possible range from the value 1, 2, or 3. The relationships with age group were adjusted for potential confounding, including BMI, age, and SES in the regression models. Adjusting for covariates, reference category, odds ratios (OR) and their respective 95% confidence intervals (CI) were reported. Results were considered to be statistically significant at P ≤ .05. All analyses were conducted using the statistical software package SPSS, version 18 (SPSS Inc., Chicago, IL, USA).

A significant difference (P > .001) between age groups was found for all FFM (Table 1). Children had lower daily breakfast consumption than seniors (72% vs 89.6%), and higher consumption of mid-morning snacks, eaten every day by nearly half of them (44%). Children and seniors had a lower rate of daily FFM (23% and 21%) compared to young adults (44%); on the contrary, the frequency of dinner showed a significant increase (P > .05) with age. There are significant differences in BMI (P > .001). As age increases, the number of people with normal body weight decreases (79% vs 36%) and instead, the number of overweight people increases (10% vs 63%). Personal perception of body mass appears to be quite unrealistic: the perception of being underweight or normal weight decreases with age, while the perception of being overweight increases in adults and decreases in seniors. In fact, two children and two adults in three were normal weight but they underestimated or overestimated their body weight. About one in three seniors was overweight (36%) but the majority classified themselves as normal weight (53%). It is mostly children who do physical exercise, and the number of people who do it 1–3 hours/week and 4 hours/week and more decreases significantly with age. On the other hand, dieting decreases significantly with age except in young adults: one in three is not dieting but would like to. Regarding perceptions of their relationship with food, the majority defined it as ‘average’, but the number of seniors who judged theirs as ‘poor’ (22%) can be contrasted with the number of adults who described theirs as ‘good’ (37%). Multinomial analysis After checking for confounders, there were no statistically significant associations for age groups in breakfast between those who ate 0–2 meals/week and those who ate 3 or more times/ week. On the contrary, children, adults, and seniors who ate seven family breakfasts per week had positive associations (P > .001) (Table 2). Compared with participants who have family meals only 0–2 times/week, seniors were 17.22 times more likely to eat breakfast and 19.5 times to eat dinner, but young adults were more likely to eat dinner (39.5 times). There were no any significant differences between those who ate mid-morning snacks 0–2 times/week compared to 3–6 times/ week, but positive associations (P > .001) were found among children, young adults, and seniors who ate snacks 7 times/week. There were significant results (P > .001) in the age groups between those who ate lunch 0–2 times/week compared to 3–6 times/week and 7 times/ week, except in the adult group. Also the comparison between those who ate dinner 0–2 times/week and 3–6 times/week showed a positive association but only in young adults; there was a highly significant association in the age groups for those who ate dinner every day, with the highest OR in adults. After checking for confounders, it was observed that the ORs of self-reported BMI were significantly associated by age group for underweight vs normal weight (P > .001), and for underweight vs overweight (P > .01), but no significant results were observed for overweight children. Regarding PBI, perceived underweight is significantly associated by age group vs normal weight (P > .005), and vs overweight (P > .003), but not among overweight children. Compared with participants who were underweight on self-reported and perceived BMI status, children were more likely to be normal weight (7.11 times) and describe themselves as normal weight (2.38 times); young adults were more likely to be normal weight

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Table 1 Percentage of frequency of family meals (in the past week), weight status, and healthy management by age group.

Frequency of meals (in the past week) Eat breakfast 0–2 times/week 3–6 times/week 7 times/week Eat mid-morning snack 0–2 times/week 3–6 times/week 7 times/week Eat lunch 0–2 times/week 3–6 times/week 7 times/week Eat dinner 0–2 times/week 3–6 times/week 7 times/week Weight status BMIb Underweight Normal weight Overweight Perceived weight status Underweight Normal weight Overweight Healthy management Physical activity Never 1–3 hours/week 4 or more hours/week Dieting? Yes No, but I would No Self-described appetite Poor Average Good

χ2

Pa

Total % (n)

Children (7–11 years) (n = 162)

Young adults (19–30 years) (n = 187)

Seniors (65–90 years) (n = 173)

12.1 (63) 12.1 (63) 75.8 (396)

13.0 15.4 71.6

17.6 15.5 66.9

5.2 5.2 89.6

28.49

***

43.7 (228) 36.4 (190) 19.9 (104)

23.5 32.1 44.4

41.2 49.7 9.1

65.3 26.0 8.7

119.97

***

58.2 (304) 11.5 (60) 30.3 (158)

61.1 15.4 23.5

38.0 17.6 44.4

77.4 1.2 21.4

68.13

***

4.6 (24) 10.2 (53) 85.2 (445)

7.4 11.7 80.9

2.1 13.4 84.5

4.6 5.2 90.2

12.59

*

8.0 (42) 60.0 (313) 32.0 (167)

11.1 79.0 9.9

11.8 65.8 22.4

1.2 35.8 63.0

129.17

***

20.3 (106) 48.9 (255) 30.8 (161)

24.1 57.4 18.5

21.4 37.4 41.2

15.6 53.2 31.2

25.66

***

53.2 (278) 24.6 (128) 22.2 (116)

19.1 41.4 39.5

54.5 21.9 23.6

83.8 11.6 4.6

142.93

***

12.1 (63) 24.9 (130) 63.0 (329)

14.2 17.9 67.9

13.9 34.2 51.9

8.1 21.4 70.5

19.93

***

14.4 (75) 55.9 (292) 29.7 (155)

13.6 57.4 29.0

7.5 55.6 36.9

22.5 54.9 22.6

20.65

***

P values generated through Chi-square analysis (χ2) for the comparison of the proportion of subjects between age groups (df = 4). BMI, body mass index. * P < .05; *** P < .001. a

b

(5.59 times), but also to perceive themselves as overweight (1.92 times); seniors were more likely to be overweight (54.49 times) and describe themselves as normal weight (3.41 times). The OR between those who do physical exercise and those who do not decreases with age. There are significant associations for physical activity in the different age groups (P > .001) between those who do not do any and those who dedicate 3 or more hours/week to it. On healthy management, children were more likely to do physical activity (2.06 times), to diet (4.78 times) and describe their appetite as average (4.23 times); young adults were more likely to describe this as average (7.43 times) or good (4.93 times); seniors were less likely to attempt weight control to lose/ gain weight (8.71 times). Regarding diet, there is a significant difference between those who diet and those who do not (P > .001) or who would like to (P > .002), except in children. In the description of appetite, those who define theirs as ‘poor’ are significantly different from those who describe theirs as ‘average’ (P > .001) or ‘good’ (P > .003), except in seniors. Discussion Research into FFM presents numerous samples of children and, in part, teenagers and a lack of involvement of young adults and seniors. Findings from the current study highlight the potential

age-related differences between FFM and weight status. The results suggest the protective nature of family meals also for young adults and seniors, and support the limited literature, which finds that the FFMs of these age groups are associated with healthy behaviour (Berge et al., 2012; Chan & Sobal, 2011). The majority of the sample state that they have breakfast every day, especially seniors (90%), while only two out of three children and adults have the same habit. After adjusting for confounders, a number of associations between age groups and FFM were statistically significant. These results are incongruent with a study on adolescents, who eat breakfast less frequently (Boutelle et al., 2001), but they confirm previous research on the habit of skipping breakfast in young people (Gillman et al., 2000; Videon & Manning, 2003) and the consumption of mid-morning snacks, which is inversely related to age. The habit of eating lunch with the family, a characteristic of the Mediterranean diet and of Italian people, appears to be significantly different in different age groups (and is most common in young adults) and is lower than national data on eating lunch at home (ISTAT, 2013). This difference can be explained by school canteens for students and day centres for seniors, who also have lunch with relatives/friends, whereas adults do not usually have canteens at work. A small minority within the age groups state that they eat dinner with the family 0–2 times/week, a positive association

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Table 2 Odds ratio and 95% CI of frequency of family meals, weight status, and healthy management by age group, adjusted for age, BMI, and SES.a

OR Frequency of meals (in the past week) Eat breakfast 0–2 times/week 3–6 times/week 7 times/week Eat mid-morning snack 0–2 times/week 3–6 times/week 7 times/week Eat lunch 0–2 times/week 3–6 times/week 7 times/week Eat dinner 0–2 times/week 3–6 times/week 7 times/week Weight status BMI Underweight Normal weight Overweight Perceived weight status Underweight Normal weight Overweight Healthy management Physical activity Never 1–3 hours/week 4 or more/week Dieting? Yes No, but I would No Self-described appetite Poor Average Good

P

CI

***

(.67–2.13) (3.47–8.79)

1.00 .88 3.79

1.00 1.37 1.89

***

(.91–2.08) (1.28–2.81)

1.00 1.21 .22

1.00 .25 .38

*** ***

(.16–.39) (.26–.56)

1.00 .46 1.16

1.00 1.19 5.52

1.00 1.58 10.92

***

Seniors (65–90 years) (n = 173)

Young adults (19–30 years) (n = 187)

Children (7–11 years) (n = 162)

OR

P

CI

OR

P

CI

***

(.53–1.45) (2.58–5.56)

1.00 .998 17.22

***

***

(.89–1.63) (.13–.37)

1.00 .39 .13

*** ***

(.28–.56 (.08–.23

***

(.31–.70) (.85–1.60)

1.00 .01 .27

*** ***

(.00–.06) (.19–.40)

(.40–2.52) (8.79–33.72)

(.77–3.26) (6.04–19.72)

1.00 6.25 39.5

*** ***

(2.18–17.96) (14.64–106.5)

1.00 1.12 19.5

***

(.43–2.92) (9.58–39.68)

(7.58–126.73) (13.46–22.69)

1.00 7.11 .89

***

(4.34–11.65) (.45–1.74)

1.00 5.59 1.91

*** *

(3.55–8.80) (1.14–3.20)

1.00 31.00 54.49

*** ***

1.00 2.38 .77

***

(1.64–3.47) (.48–1.24)

1.00 1.75 1.92

** ***

(1.19–2.58) (1.31–2.82)

1.00 3.41 1.99

*** **

(2.22–5.23) (1.26–3.17)

*** ***

(1.41–3.31) (1.34–3.17)

1.00 .40 .43

*** ***

(.28–.58) (.30–.61)

1.00 .14 .06

*** ***

(.09–.22) (.03–.11)

1.00 1.26 4.78

***

(.73–2.18) (3.05–7.50)

1.00 2.46 3.73

*** ***

(1.56–3.88) (2.42–5.75)

1.00 2.64 8.71

** ***

(1.43–4.89) (5.01–15.15)

1.00 4.23 2.14

*** **

(2.66–6.73) (1.29–3.54)

1.00 7.43 4.93

*** ***

(4.25–12.98) (2.77–8.75)

1.00 2.44 .979

***

(1.68–3.54) (.64–1.56)

1.00 2.16 2.06

a OR, odds ratio; CI, confidence interval; BMI, body mass index; SES, Socio-economic status. P values generated through multinomial regression model (adjusted for age, BMI and SES), in comparison for Frequency of family meals (compared to those who report 0–2 times/week), Weight status (compared to Underweight), and Healthy management (compared to No physical activity, Dieting, and Poor appetite). * P < .05; ** P < .01; *** P < .001.

with the vast majority of children (81%), young adults (84%) and seniors (90%) who have dinner with the family 7 times/week. These data show a higher frequency of dinner in the family compared to other studies in other countries (Fulkerson et al., 2014; Holmes et al., 2008; Taveras et al., 2005). Differences in the prevalence of family dinner may have occurred because of methodological variations, including differences in samples from different nations even within the European Union (Steenhuis et al., 2006; Veltsista et al., 2010), and different cultures, such as the traditional Italian family dinner and the Mediterranean diet (Madrigal et al., 2000; Sánchez-Villegas et al., 2001; Tessier & Gerber, 2005). Associations between age group and any of the body weight measurements (self-reported and perceived) in young adults and seniors (but not in overweight children) are congruent with previous reports, which show a higher likelihood of underestimating oneself in Mediterranean populations and in seniors more than adults or children. So there is an age-modified association between self-reported BMI and adequate PBI (Madrigal et al., 2000; Sánchez-Villegas et al., 2001). These results are incongruent with

a few studies that reported no relationship (Sobal & Hanson, 2011; Steenhuis et al., 2006) or an inverse relationship (Gillman et al., 2000; Sen, 2006). The high FFM suggests psychological control over children by adults and seniors, who act as models for healthy eating, with an influence on weight that involved the same relatives in the first place (Sobal & Hanson, 2011). To confirm this, research shows no relationship between FFM and body weight in families with no children and an inverse relationship in families with children (Abraczinskasa et al., 2012; Sobal & Hanson, 2011). The absence of a significant association in children between underweight and overweight, self-reported and perceived, suggests both lack of awareness of average weight in their age group and an insufficient direct or indirect influence of relatives in lowering body mass levels (Abraczinskasa et al., 2012). In estimating the influence of the protective nature of FFM on weight status and strategies for healthy management, there appears to be higher associations within age groups but also many agerelated discrepancies. Compared with those who eat family meals 0–2 times/week, children who tend to eat breakfast, mid-morning

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snack and dinner with their family are more likely to be associated with normal weight and physical exercise (but not with dieting), and describe their appetite as ‘average’. Young adults skip breakfast and mid-morning snacks more often, but are more likely to eat lunch and dinner with their family. A large majority are normal weight, but one out of three perceive themselves as overweight and therefore do physical activity or diet. As age increases, the number of hours of physical exercise decreases, but the desire to lose weight increases, as does their description of their appetite as ‘average’ or ‘poor’. The senior group are more likely to eat breakfast and dinner with their family, but also do less physical exercise and diet less than other age groups. In older people, the higher OR on “eat dinner 7 times/week,” “weight status” and “selfdescribed appetite,” which decreases when they live in care homes (Leslie, 2011), can reflect a complex combination of hormonal and weight change factors due to their changing body composition and fat mass (Sánchez-Villegas et al., 2001). The highest number of overweight people in the seniors who describe their appetite as ‘poor’ can also reflect an agreement with “are overweight but not trying to change this” (Steenhuis et al., 2006). Findings from the current study mirror the differential protective nature of FFM for children, young adults and seniors. These findings also suggest their different age-related associations with both weight status and health management. Conclusion From logistic regression analysis, age group was found to have a consistent (and different) influence on family meal frequency, on self-reported and perceived BMI status, on healthy behaviour such as frequency of physical activity, dieting and perceived appetite. Skipping breakfast and eating mid-morning snacks, together with the discrepancy in the fact that self-reported overweight was half that of perceived body weight in young adults, and partly in children, shows poor assessment of body weight, which confirms other studies on the misperception of body weight (Steenhuis et al., 2006). Educational programmes about “what is a healthy and desirable weight” (Videon & Manning, 2003) represent a relevant factor in the promotion of weight and food management and prevention of eating disorders. Limits, implications for research and practice The study showed various limitations. BMI was determined by self-reported measurements of weight and height; so FFM, weight status and food management were based on self-reported measurements. These estimates are considered as a proxy indicator of body weight status (Sánchez-Villegas et al., 2001; Veltsista et al., 2010); however, further research can confirm the results with clinical measurements. Another priority of future research will be to assess the quality of each food consumed at each meal. Also, the generalisability of this study findings is limited to the geographical area of Sardinia (Italy). Finally, the sample does not include the teenager and adult age groups and therefore does not clarify their associations over a whole lifespan. Further research into healthy nutrition education could focus on the coherence between self-representation compared with the type of diet with a quantitative analysis of food and any gender differences. Other studies could widen our perspective on parental– child agreement on the perception of their family style of diet (Uccula, Nuvoli, & Aiello, 2012), for changes in nutrition education, which increases awareness of their own body weight from the early stages of puberty. This stems from positive experiences gained during the periodical transfer of information about children’s weight to their parents in order to monitor the risks of

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over/under eating (Kubik, Fulkerson, Story, & Rieland, 2006). Risks of malnutrition among the elderly population suggest the need for nutrition education programmes across our whole lifespan.

Appendix Questionnaire (Just ONE answer to each question) Frequency of meals 1Q. During the past week, how many days did you eat breakfast in your family? 1. Never [_] 2. 1 or 2 times/week [_] 3. 3–4 times/week [_] 4. 5–6 times/week [_] 5. Every day/week [_] 2Q. During the past week, how many days did you eat a snack in your family? 1. Never [_] 2. 1 or 2 times/week [_] 3. 3–4 times/week [_] 4. 5–6 times/week [_] 5. Every day/week [_] 3Q. During the past week, how many days did you eat lunch in your family? 1. Never [_] 2. 1 or 2 times/week [_] 3. 3–4 times/week [_] 4. 5–6 times/week [_] 5. Every day/week [_] 4Q. During the past week, how many days did you eat dinner in your family? 1. Never [_] 2. 1 or 2 times/week [_] 3. 3–4 times/week [_] 4. 5–6 times/week [_] 5. Every day/week [_]

Healthy management 5Q. How do you consider your body? 1. I am very much underweight 2. I am a little underweight 3. I am normal weight 4. I am a little overweight 5. I am very much overweight 6Q. How would you describe your appetite? 1. Never get hungry 2. Poor appetite 3. Average appetite 4. Good appetite 5. Excellent appetite 7Q. During the past week a) How many hours of physical and sporting activities you do? 1. Never 2. From 1 to 3 hours 3. 4 or more hours b) Have you dieted to lose weight or gain weight? 1. Yes 2. No 3. No, but I would

[_] [_] [_] [_] [_] [_] [_] [_] [_] [_] did [_] [_] [_] [_] [_] [_]

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